Following bariatric surgery, use of opioids increases among chronic opioid users

October 1, 2013

In a group of patients who took chronic opioids for noncancer pain and who underwent bariatric surgery, there was greater chronic use of opioids after surgery compared with before, findings that suggest the need for proactive management of chronic pain in these patients after surgery, according to a study in the October 2 issue of JAMA.

"Bariatric surgery is used to treat obesity, as well as its comorbid conditions such as cardiovascular and metabolic diseases and chronic pain. Bariatric surgery-related weight loss is associated with improvements in osteoarthritis-associated knee pain and function and decreased back pain in observational studies," according to background information in the article. "Because some pain syndromes are related to obesity, it is reasonable to assume that weight loss may be associated with better pain control." It is not known if opioid use for chronic pain in obese individuals undergoing bariatric surgery is reduced.

Marsha A. Raebel, Pharm.D., of Kaiser Permanente Colorado, Denver, and colleagues conducted a study to examine opioid use following bariatric surgery in patients using opioids chronically for pain control prior to their surgery. The study included 11,719 individuals 21 years of age and older who had bariatric surgery between 2005 and 2009, and who were assessed 1 year before and after surgery, with latest follow-up by December 31, 2010.

In the year before bariatric surgery, 56 percent of patients had no opioid use, 36 percent had some opioid use, and 8 percent had chronic opioid use. Among pre-surgery chronic users, 77 percent continued chronic opioid use after surgery. Relative to the year before surgery, the amount of opioid use by patients who were chronic opioid users before surgery increased by 13 percent the first year after surgery and by 18 percent across 3 post-surgery years.

For the group with chronic opiate use prior to surgery, change in morphine equivalents before vs. after surgery did not differ between individuals who lost more than 50 percent of their excess body mass index vs. those who lost 50 percent or less.

"We anticipated [that] weight loss after bariatric surgery would result in reduced pain and opioid use among patients with chronic pain. However, patients with and without preoperative chronic pain, depression diagnoses, or both had similar increases in postoperative chronic opioid use after surgery as those without chronic pain or depression. One possible explanation is that some patients likely had pain unresponsive to weight loss but potentially responsive to opioids," the authors write.

"These findings suggest the need for better pain management in these patients following surgery."

In an accompanying editorial, Daniel P. Alford, M.D., M.P.H., of Boston Medical Center, discusses the importance of clinicians reducing or eliminating opioid use among patients when warranted.

"The safe and appropriate prescribing of opioids for chronic pain has become an important national priority. Although core competencies for pain management are being developed, knowing when and how to continue, change, or discontinue opioid therapy must be included in all clinician education efforts. Although Raebel et al are correct in reporting that better pain management strategies are needed, they also may have uncovered an equally important problem—the need to know if, when, and how to safely and effectively taper or discontinue opioid therapy for patients with chronic pain."

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